Pulmonary carcinosarcoma: analysis from the Surveillance, Epidemiology and End Results database

Epidemiology, site-specific characteristics and survival of carcinosarcoma: a retrospective study based on SEER database

OBJECTIVES

Carcinosarcoma (CS) is a rare and biphasic malignancy characterised by a highly invasive biological nature and poor prognosis. This study explored the epidemiology, site-specific characteristics and survival outcome of CS.

DESIGN

We conducted a retrospective study in the Surveillance, Epidemiology and End Results (SEER) database (1975-2018) for primary CS.

SETTING AND PARTICIPANTS

SEER database includes publicly available information from regional and state cancer registries in the US centres. A total of 5042 CS patients were identified. We selected the top five anatomic CS (uterus, double adnexa, lung, bladder and breast) patients for further analysis.

PRIMARY OUTCOME MEASURES

Incidence was estimated by geographical region, age, sex, race, stage and primary site. Trends were calculated using joinpoint regression. The cancer-specific survival (CSS) rate and initial treatment were summarised.

RESULTS

Nearly 80% of CS occurred in the uterus and double adnexa, followed by lung, bladder and breast. The elderly and black population presented the highest age-adjusted rate of CS. The rates of distant metastasis in CS progressively increased from 1989 to 2018. Atlanta was the area with the highest incidence at 0.7 per 100 000. Pulmonary and bladder CS more frequently occurred in men and were diagnosed with regional stage. Distant metastasis was mostly found in ovary/fallopian tube CS. Radiotherapy was more commonly applied in uterine CS, while adnexa CS cases were more likely to receive chemotherapy. Multiple treatments were more used in breast CS. Pulmonary CS seemed to suffer worse CSS (median: 9.92 months), for which radiotherapy might not provide survival benefits (HR 0.60, 95% CI 0.42 to 0.86). Compared with the common histological types in each site, CS had the shortest survival.

CONCLUSIONS

CS has unique clinical features in each primary site. Substantial prognosis variances exist based on tumour locations. The aggressive course is the common feature in CS at all sites.

Epidemiology and prediction model of patients with carcinosarcoma in the United States

Background

Carcinosarcoma is a rare biphasic tumor composed of both carcinoma and sarcoma elements, which occurs at various sites. Most studies are case reports or small population-based studies for a single disease site, so comprehensive evaluations of epidemiology and prognostic factors for carcinosarcoma are needed.

Methods

Surveillance, Epidemiology, and End Results (SEER)-8 (1975-2019) provided data for the epidemiological analysis. SEER-17 (2000-2019) provided data on the primary tumor sites, initial treatment, construction, and validation of the nomogram.

Results

The age-adjusted incidence per 100,000 persons of carcinosarcoma increased significantly from 0.46 to 0.91 [1975-2019; average annual percent change (AAPC): 1.3%, P = 0.006], with localized stage increasing from 0.14 to 0.26 [2005-2015; annual percent change (APC): 4.2%]. The 20-year limited-duration prevalence per 100,000 increased from 0.47 to 3.36 (1999-2018). The mortality per 100,000 increased significantly from 0.16 to 0.51 (1975-2019; AAPC: 1.9%, P < 0.001). The 5-year relative survival was 32.8%. The greatest number of carcinosarcomas were from the uterus (68.7%), ovary (17.8%), lung and bronchus (2.3%). The main treatment is comprehensive treatment based on surgery; however, surgery alone is preferred in older patients. In multivariate analysis (N = 11,424), age, sex, race, year of diagnosis, disease stage, tumor site, and treatment were associated with survival. A nomogram was established to predict 1-, 3-, and 5-year survival, and the C-indexes were 0.732 and 0.748 for the training and testing sets, respectively. The receiver operating characteristic curve demonstrated that the nomogram provided a comprehensive and accurate prediction [1-year area under the curve (AUC): 0.782 vs. 0.796; 3-year AUC: 0.771 vs. 0.798; 5-year AUC: 0.777 vs. 0.810].

Conclusions

In this study, the incidence, prevalence, and mortality of carcinosarcoma have increased over the past decades. There was a rapid rise in the incidence of localized stage in recent years, which reflected improved early detection. The prognosis of carcinosarcoma remains poor, signifying the urgency of exploring targeted cancer control treatments. Explicating distribution and gender disparities of carcinosarcoma may facilitate disease screening and medical surveillance. The nomogram demonstrated good predictive capacity and facilitated clinical decision-making.

Long-term survival analysis of sublobar resection versus lobectomy for older patients with early-stage pulmonary carcinoid tumour: a database-based propensity score-matched study

BACKGROUND

The optimal extent of surgery for older patients with early-stage pulmonary carcinoid tumour (PC) remains controversial.

AIMS

To compare prognostic differences between sublobar resection versus lobectomy in older patients with early-stage PC.

METHODS

The SEER database was searched for stage T1N0M0 PC patients aged ≥ 65 years who underwent lobectomy or sublobar resection from 2000 to 2017. Propensity score matching (PSM) was used to determine intergroup covariate differences. Kaplan-Meier curves and the log-rank test were used for intergroup comparison of overall survival (OS). A Cox proportional hazard model was used to evaluate independent risk factors.

RESULTS

Among 1023 participants, 650 and 373 underwent lobectomy and sublobar resection, respectively. Before PSM, the 5- and 10-year OS in the sublobar resection group were lower than that of the lobectomy group (5-year OS 84.12% vs. 91.16%; 10-year OS 57.43% vs. 64.77%; p = 0.014); after PSM, no significant prognostic difference existed between lobectomy and sublobar resection (5-year OS 88.17% vs. 89.23%; 10-year OS 58.32% vs. 62.75%; p = 0.811). Subgroup analysis included tumour size, age, number of lymph nodes examined and histological type, and showed no statistically significant survival differences between the lobectomy and sublobar resection groups. Multivariable Cox analysis indicated that age ≥ 77 years, male sex, inadequate lymph node assessment (< 7), and atypical carcinoid were associated with reduced OS.

CONCLUSION

Sublobar resection showed a similar long-term survival rate for early-stage PC patients aged ≥ 65 years as with lobectomy, thereby providing a basis for the selection of surgical methods for PC.

Establishment of a Competing Risk Nomogram in Patients with Pulmonary Sarcomatoid Carcinoma

Background and aim: Pulmonary sarcomatoid carcinoma (PSC) is a rare subtype of nonsmall cell lung cancer with a poor prognosis. This study aimed to analyze the clinicopathological characteristics and survival outcomes among patients with PSC, lung squamous cell cancer (SCC), and lung adenocarcinoma (LAC), and to construct a competing risk nomogram for patients with PSC. Method: Data of 3 groups of patients diagnosed with PSC, SCC, or LAC from the surveillance, epidemiology, and end results (SEER) database between 1988 and 2015 were retrospectively reviewed. A 1:1 propensity score matching (PSM) analysis was used to balance the baseline data of patients. Independent risk factors associated with survival outcomes were screened by the least absolute shrinkage and selection operator and further determined by univariate and multivariate Cox proportional risk regression analyses. The overall survival (OS) of patients was evaluated by Kaplan–Meier analysis and compared with a log-rank test. The cumulative incidence function was used to estimate the 5-year probabilities of the cancer-specific mortality of PSC. A nomogram was constructed to illustrate the competing risk model to predict the 3- and 5-year OS, and corresponding concordance indexes (C-indexes) and calibration curves were used to assess and validate the competing risk nomogram. Results: A total of 2285 patients with PSC were included in this study. Compared with SCC and LAC patients, the Kaplan–Meier analysis showed that patients with PSC had a worse prognosis, with a median survival of 5 months (95% confidence interval [CI]: 5-6 months) and a 5-year OS rate of 15.3% (95% CI: 13.9%-16.9%). Similar outcomes were demonstrated after 1:1 PSM. Moreover, the competing risk model showed that age, T stage, M stage, tumor size, lymph node ratio (LNR), surgery, and chemotherapy were associated with PSC-specific mortality. The 5-year C-index of the nomogram was 0.718. Calibration curves illustrated that the nomogram was well-validated and had great accuracy. Conclusions: Patients with PSC had a worse survival outcome compared with SCC or LAC patients. Age, T stage, M stage, tumor size, LNR, surgery, and chemotherapy were associated with PSC-specific mortality. The competing risk nomogram displayed excellent discrimination in predicting PSC-specific mortality.

The Prognosis of Pulmonary Sarcomatoid Carcinoma: Development and Validation of a Nomogram Based on SEER

Background: The rarity of pulmonary sarcomatoid carcinoma (PSC) and the lack of prospective clinical trials have led to limited knowledge of its clinical characteristics. This study aimed to evaluate the survival and prognostic factors of PSC and to build a nomogram for clinical practice. Methods: Eligible patients diagnosed from 2010 to 2016 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. We compared the clinical characteristics and survival times of PSC patients with those of lung adenocarcinoma (LADC) and lung squamous cell carcinoma (LSCC) patients. We also used univariate and multivariable Cox regression to estimate mortality hazard ratios among patients with PSC, while a visual nomogram was established to judge the prognosis. Discrimination, calibration, clinical utility, and reproducibility were validated by Harrell's concordance index (C-index), the area under the curve (AUC), calibration curves, and decision curve analysis (DCA). Results: A total of 400 PSC patients (0.42%) were identified in the SEER database, whereas 58 474 and 33 637 patients were diagnosed with LADC and LSCC, respectively. Age, T stage, grade, surgery, and radiation were shown to be significant prognostic factors in the Cox regression analyses and were included in the nomogram as predictors. The C-index of the nomogram in the validation set was 0.759. The AUC also demonstrated the good performance of the nomogram, and DCA demonstrated its good clinical applicability. Conclusion: We established a novel nomogram to predict the prognosis of PSC, which can help clinicians make tailored decisions and adjust follow-up management strategies, and can provide accurate and individualized survival predictions.

Stereotactic body radiation therapy for an octogenarian with pulmonary carcinosarcoma

Pulmonary carcinosarcoma is a rare lung tumor accounting for <1% of primary lung cancers, characterized by biphasic components with both carcinomatous and sarcomatous mesenchymal features. This report describes a case of pulmonary carcinosarcoma in an octogenarian who was treated with stereotactic body radiation therapy (SBRT) and whose therapeutic response was sustained for 2 years. Along with other treatment modalities, SBRT might be considered for the treatment of medically inoperable localized stage pulmonary carcinosarcoma.

Next-Generation Sequencing Analysis Identified Genomic Alterations in Pathological Morphologies of 3 Cases of Pulmonary Carcinosarcoma

Background

Pulmonary carcinosarcomas (PCSs) are a heterogeneous group of non-small-cell lung carcinomas (NSCLCs) with aggressiveness and a poor prognosis. Although genetic mutations of some common lung cancer subtypes have been extensively studied, the molecular characteristics of PCSs and the existence of abnormal target genes are unknown.

Methods

In this study, the clinical and molecular characterization in 3 pulmonary sarcomatoid carcinomas (PSCs) were presented using microscope analysis and next-generation sequencing (NGS) analysis.

Results

The results revealed a carcinosarcomas subtype presenting squamous cell carcinoma and sarcoma components in all 3 cases. NGS analysis showed that 182, 316 and 230 shared mutations were detected between sarcoma and lung carcinoma from 3 patients. Two identical alterations in two genes (CSMD3 and RYR3) that were all shared by the two components in 3 patients. Tumor suppressor gene TP53 (5/6, 83%) showed the highest mutation frequency for driver genes here. Additionally, we focused on an LYST mutation which was mainly present in the sarcoma components. Moreover, the clonal evolution and signature analysis confirm that lung squamous cell carcinoma and sarcoma in each PCS patient may have come from a common ancestor, and mutagenesis was possibly related to indirect effects of tobacco, age or other unknown factors.

Conclusion

Our results indicate that genetic analysis and molecular targeted therapy are necessary for the identification and treatment of these rare lung tumors. CSMD3 and LYST, as common mutation genes, may be a potential therapeutic target in PCS.

Pulmonary Sarcomatoid Carcinoma: Experience From SEER Database and Shanghai Pulmonary Hospital

BACKGROUND

Pulmonary sarcomatoid carcinoma (PSC) is a rare type of lung cancer. This study aimed to explore the appropriate treatment for PSC.

METHODS

Two cohorts were used: patients from the Surveillance, Epidemiology, and End Results (SEER) database (1988 to 2014) and Shanghai resident patients at Shanghai Pulmonary Hospital (2009 to 2019) in China. Cox regression analysis was applied to identify prognostic factors for progression-free survival and overall survival (OS). Interaction assessments were performed using likelihood ratio tests to examine relationships between adjuvant chemotherapy and other baseline characteristics.

RESULTS

In the SEER cohort, 1640 patients with PSC were identified, with a median survival and a 5-year OS rate of 7 months (95% confidence interval (CI), 6 to 8 months) and 19.5%, respectively. Multivariable Cox analysis of surgically treated patients revealed that adjuvant chemotherapy was significantly associated with better survival (hazard ratio, 0.78; 95% CI, 0.62 to 0.98), and the benefit was more pronounced in T3 to T4 stage (P = .04) and N-positive patients (P < .01). In the Shanghai Pulmonary Hospital cohort (n = 175), the median progression-free survival and OS were 8 months (95% CI, 7 to 12 months) and 12 months (95% CI, 10 to 18 months), respectively, with a 5-year OS rate of 25.1%. Similarly, the survival benefit of adjuvant chemotherapy was confirmed in patients with surgical resection (hazard ratio, 0.50; 95% CI, 0.31 to 0.81), but this benefit was restricted to patients who were younger (age <63 years; P = .02) and had a higher body mass index (>25 kg/m²; P < .01) by interaction assessments. The disease control rate after chemotherapy was 58.62%, and the disease control rate after targeted therapy was 57.14%.

CONCLUSIONS

Adjuvant chemotherapy should be recommended for patients with surgically treated PSC, especially for patients with advanced-stage cancer, younger age, or higher body mass index.